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General NPI Number Information
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NPI Number | 1841956778
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Entity Type | Individual
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Provider Name | KEITH STEPHEN PERNELL PA
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Gender | Male
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Dates
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Enumeration Date | 11/15/2021
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Last Update Date | 01/04/2024
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Provider Practice Location Address
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Address Line | 9300 DEWITT LOOP
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City | FORT BELVOIR
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State | VA
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Zip | 22060-5285
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Country | US
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Telephone | 571-231-1868
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Fax |
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Provider Business Mailing Address
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Address Line | 42427 IBEX DR
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City | STERLING
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State | VA
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Zip | 20166-2234
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Country | US
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Telephone | 808-375-7717
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA20001279
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110007956
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License Number State | VA
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